Population Cardiovascular Health and Urban Environments: The Heart Healthy Hoods exploratory study in Madrid, Spain

Population Cardiovascular Health
and Urban Environments: The Heart
Healthy Hoods exploratory study in
Madrid, Spain
ICUH, April 2016, SF
Usama Bilal1,2(ubilal@jhmi.edu), Julia Díez1, Silvia
Alfayate1, Pedro Gullón1,3, Isabel del Cura4,5,
Francisco Escobar6, María Sandín1, Manuel Franco1,2
1. Social and Cardiovascular Epidemiology Res. Group, Universidad de Alcala, Madrid, Spain
2. Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
3. Unidad Docente Medicina Preventiva y Salud Pública, National School of Public Health, Madrid, Spain.
4. Primary Care Research Unit. Gerencia de Atención Primaria. Madrid. Spain.
5. Department Preventive Medicine and Public Health, University Rey Juan Carlos, Madrid, Spain
6. Department of Geology, Geography and Environment, Faculty of Biology, Chemistry and Environmental
Sciences, University of Alcalá, Alcalá de Henares, Madrid, Spain.
Currently Under Review at BMC Medical Research and Methodology

http://hhhproject.eu
Background
• Cardiovascular diseases (CVD) 1st cause of death (1)
• Population preventive approaches needed (2)
• Neighborhoods offer opportunities for policy (place-
based) interventions to address CVD (3)
• Mixed methods and GIS can help provide a better
characterization of residential environments
References: (1) Beaglehole and Bonita, Lancet 2008; (2) Rose, Int J Epidemiol, 1985; (3) Franco, Bilal
and Diez-Roux, J Epidemiol Comm Health 2015

Objectives
1. To Describe the cardiovascular health profile of a
population over 15,000 residents living in an area,
analyzing the Madrid Primary Health Care System
electronic health records
2. To Explore different quantitative and qualitative
measurements to characterize the social and physical
urban environment in relation to food, alcohol, tobacco
and physical activity

Setting
• Average area in 4 variables (Median Neighborhood Index)
– Aging: % > 65 years of age or above
– Immigration (marker for segregation): % foreign-born
– Education (marker for SES): % with primary education or below
– Density: population/km2
• Looked for clusters of areas of ~15,000 people with a low
value in the index (-> non-extreme areas)

Methods (quantitative)
• Cardiovascular Disease:
– Whole population (>99%) EHR through universal health system.
– Validated (1) data on physician-diagnosed: diabetes,
hypertension, dyslipidemia, smoking and obesity.
• Urban environment
– Food: location and type of food stores and food services, directly
measured healthy food availability (brief NEMS-S)
– Physical activity: SPACES audit tool for walkability and bikeability,
SOPARC audit tool for open spaces.
– Alcohol and tobacco: location and type of retailers
References: (1) de Burgos Lunar et al, BMC Med Res Methodol, 2013.

Methods (qualitative)
• 11 semi-structured interviews with key informants: 4 long-
term residents, 2 immigrants, 1 teacher, 1 community
activist, 1 health care provider, 1 public health officer, 1
local food store owner
• Questions on health and the environment, focusing on
sociodemographics, food, alcohol, tobacco and physical
activity.
• Analysis by triangulation incorporating an interpretative
phenomenological analysis.

Methods (integration)
• Geographic Information Systems
– Directly collected data + Secondary administrative data
– Joined to street sections by relational union or overlaid as
administrative boundaries/blocks.
• Mixed Methods Approach: merging approach to combine
– Provides insights on quantitative findings
• Quantitative -> qualitative
– Guides future quantitative data collection (formative)
• Qualitative -> quantitative.

Results
Photos by Victor Carreño and Franco M, Gullon P, Carreño V. Studying city life, improving population health. Int J Epidemiol 2015

Results
Alcohol
(Restaurants and Liquor Stores)
Food Services
(Bars, Restaurants and Fast Food)
Tobacco
(Vending Machines & Stores)

Results
• Use of parks was diverse, with levels of activity varying
from sedentary (sitting), walking and vigorous (sports)

HHH Pilot Study
Qualitative Study
Food Environment: “I have my children and many years, so I
know what is good and what is bad…what one can afford is
different” (woman, >65 years)

HHH Pilot Study
Qualitative Study
Physical Activity Environment: “ When we are older,
because I’m on a wheelchair in the street … If I had benches
there, I would not need the wheelchair, because walking 20
meters is fine, but maybe 25 meters isn’t.” (Woman, > 65
years)

HHH Pilot Study
Qualitative Study
Alcohol Environment: “Social drinking customs are
disappearing, we used to go on Sundays to have a vermouth
with your neighbors and your friends. Nowadays, people are
doing it less, because of the economic crisis” (Food store
owner).

Pilot Qualitative Study
Emergent categories
The role of immigration in shaping behavior patterns related
to the use of open spaces "... In the past other people would go
there [park], but now the Romanians are there..." (men, < 65 years )

Emergent categories
The current economic crisis shaping the neighbor’s
behaviors "... Nowadays there are a lot of grandparents taking care
of the family…. Many unemployed descendants. So there is little
time for healthy habits like exercise... " (health care provider,
woman)

Emergent categories
The role of social networks shaping health behavior patterns
in residents "I'm happy with people in my neighborhood. Since my
husband died, ... adults and kids alike, boys like my sons, 50 years-
old, [have told me] ‘hey, I work on this, if I can help you... I will help
you with stuff if you ask me’ " (woman, > 65 years)

Conclusions
• Challenges in measuring a food environment that is much
more dense compared to US/UK/etc.:
– How to measure food markets and dense food environments?
– How to incorporate perceptions?
• Limited information on tobacco in qualitative interviews:
– Use of focus groups?
• Integration of all the information in GIS
– Composite indices?
Comparing local availability
and accessibility to healthy
foods across countries: A
case study in Madrid (Spain)
and Baltimore (USA)
J. Diez (Sun/16:00)
Healthy urban environment
characterization focused on
physical activity and food: A
GIS-based method
A. Cebrecos (Fri/8:00)
Studying the Perceived local
food environment through
individual spatial cognition
analysis: a case study in
Madrid
R. Valiente (Fri/8:20)

Photos by Victor Carreño and Franco M, Gullon P, Carreño V. Studying city
life, improving population health. Int J Epidemiol 2015

Population Cardiovascular Health and Urban Environments: The Heart Healthy Hoods exploratory study in Madrid, Spain

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